84.07 Two Enhanced Recovery After Pancreatectomy Protocols Do Not Offer Similar Results

Posted on January 18, 2018

A. McQuaid1, K. Subramaniam2, M. Boisen2, S. Esper2, K. Meister2, J. Gealey2, J. Holder-Murray3, A. Hamad3, M. Hogg3, H. Zeh3, A. Zureikat3  1University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,Department Of Anesthesia,Pittsburgh, PA, USA 3University Of Pittsburgh Medical Center,Department Of GI Surgical Oncology,Pittsburgh, PA, USA

Introduction: Enhanced recovery protocols in pancreatic surgery have been shown to reduce length of hospital stay without compromising outcomes. Assessing the relative contribution of individual interventions, however, is difficult when multiple practice changes are implemented simultaneously. We implemented similar pancreatectomy pathways that differ in anesthesia management at 2 hospitals with the same group of surgeons. We aimed to compare pain management and outcomes in these 2 groups with the purpose of implementing the best practice system-wide.

Methods: Patients who underwent pancreatic surgery between July 2015 and May 2017 on an enhanced recovery pathway were included. Hospital A patients received intrathecal morphine, whereas Hospital B patients received quadratus lumborum/transversus abdominal plane blocks. Data were retrospectively extracted from the electronic medical record and from a prospectively collected institutional database. Patients were analyzed according to the hospital where they received care (Hospital A, n=226, Hospital B, n=45) by univariate analysis. We also performed 2:1 propensity matched analysis (45 Hospital B patients were matched to 90 Hospital A patients) to account for potential confounding factors including comorbidities and at-home prior medications that could affect post-operative experience of pain. Primary outcomes were opioid consumption and average visual analog pain scores. Secondary outcomes were length of hospital and PACU stay, ICU admission, extubation location, ondansetron requirement, time to first bowel movement, local and systemic complications, readmission, and mortality. SPSS version 24 was used for analysis.

Results: Postoperative analgesia was superior on postoperative day 0 in patients who received intrathecal morphine (Hospital A) by both univariate and propensity matched analysis. Among matched groups, Hospital A had a significantly reduced median intravenous morphine equivalent consumption on day 0 [(Hospital A 2.6 mg (0.0-8.5), Hospital B 8.0 mg (0.0-24.4), p=0.002] and median visual analog pain score on days 0 and 5 [Hospital A 4.2 (2.0-5.6) and 4.0 (3.0-5.15), Hospital B 5.7 (2.9-6.9) and 5.7 (3.7-6.2), p=0.01, 0.029]. Although opioid consumption and pain scales did not reach statistical significance on other postoperative days, there was a consistent trend towards superior pain relief for Hospital A patients. Hospital B patients were also significantly less likely to undergo extubation in the operating room (Hospital A 94.4%, Hospital B 62.2%, p=0.006). Wound infection was higher in Hospital B (p=0.02), whereas pancreatic leak was higher in Hospital A (p=0.011). All other variables did not differ significantly.

Conclusion: Intrathecal morphine based enhanced recovery protocols improved postoperative pain relief over nerve block based. The relation between pain management protocols and incidence of wound infection and pancreatic leaks requires further evaluation.

 

84.03 The Effects of Morbid Obesity on Outcomes Following Pancreaticoduodenectomy for Pancreatic Cancer

Posted on January 18, 2018

E. H. Chang1, P. L. Rosen1, D. J. Gross1, V. Roudnitsky2, M. Muthusamy4, G. F. Coppa3, G. Sugiyama3, P. J. Chung4  1State University Of New York Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 2Kings County Hospital Center,Division Of Trauma And Acute Care Surgery,Brooklyn, NY, USA 3Hofstra Northwell School Of Medicine,Department Of Surgery,Hempstead, NY, USA 4Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction: An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for pancreatic cancer. Obese patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer have reduced long-term survival compared to non-obese patients, however the effects of increasing BMI on short-term postoperative outcomes are mixed. Therefore our goal is to elucidate the effects that morbid obesity has on outcomes after PD for pancreatic head cancer using a national, prospectively maintained clinical database.

Methods: Using the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database we identified cases of PD (CPT 48150) for pancreatic head cancer (ICD 9 157.0), excluding cases that were emergent, had contaminated/dirty wound class, and missing outcomes data. Multiple imputation was performed for missing risk variables. Morbid obesity was defined as a BMI ≥35 kg/m2. Propensity score analysis was used to match morbidly obese patients to control. Outcomes of interest included 30-day postoperative mortality and complications (infectious, wound, pulmonary, renal, cardiovascular, and septic), and return to operating room, which were evaluated using conditional logistic regression.

Results: A total of 4,387 patients were identified and 390 (8. 9%) were morbidly obese. These patients were younger (mean 62.2 vs 66.4 years, p<0.0001), more likely to be female (60.0%, p<0.0001), have insulin-dependent diabetes (27.2% vs 15.1%, p<0.0001), dyspnea with moderate exertion (11.0% vs 5.8%, p=0.0007), hypertension (75.8% vs 55.3%, p=0.0001), and had higher proportions of patients who were African American (11.8% vs 8.8%, p=0.001), ASA class 3 (76.7% vs 69.8%, p=0.005), and had longer operative times (mean 421.7 vs 388.3 minutes, p<0.0001). Propensity score matching identified 381 morbidly obese to 1,102 control cases that were well balanced along all covariates. Morbid obesity was associated with higher risk of organ space surgical site infection (OR 1.54, 95%CI [1.09, 2.18], p=0.014), unplanned reintubation (OR 1.77, 95% CI [1.08, 2.89], p=0.023), pulmonary embolism (OR 2.92, 95%CI [1.02, 8.32], p=0.046), failure to wean from ventilator (OR 2.40, 95%CI [1.46, 3.94], p=0.00059), renal insufficiency (OR 2.87, 95%CI [1.14, 7.24], p=0.026), septic shock (OR 2.31, 95%CI [1.35, 3.93], p=0.0021), return to operating room (OR 1.81, 95%CI [1.14, 2.89], p=0.013), and mortality (OR 2.31, 95%CI [1.09, 4.89], p=0.029).

Conclusion: In this large observational study, morbid obesity in patients undergoing pancreaticoduodenectomy for head of pancreas cancer was associated with increased risk of postoperative complications and mortality. Clinicians should be aware of these increased risks and prospective studies to identify preoperative and perioperative factors that will mitigate these adverse outcomes are warranted.

84.04 The Role of a Multidisciplinary Tumor Board in Management of Patients with Pancreatic Cystic Lesions

Posted on January 18, 2018

K. Rawlins1, C. McQuinn2, E. B. Schneider2, P. Muscarella3, M. Dillhoff2, C. R. Schmidt2, L. A. Shirley2  1Ohio State University,College Of Medicine,Columbus, OH, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA 3Albert Einstein College Of Medicine,Department Of Surgery,Bronx, NY, USA

Introduction: Pancreatic cystic lesions are being increasingly discovered due to use of axial imaging. Since risk of malignancy varies greatly based upon lesion type, we sought to examine whether case presentation to a multidisciplinary tumor board was associated with changes in working diagnosis and treatment plan.

Methods: We reviewed all patients who were presented to our institution’s tumor board with a pancreatic cystic lesion from 2012-2015. Patients were divided into six categories based upon lesion type. Pre-discussion diagnosis and treatment plan were compared to post-discussion diagnosis and plan. Corresponding change in diagnosis and plan were examined according to lesion type. Changes in plan were assessed by whether the change was from a less aggressive to a more aggressive treatment option or vice versa. The implementation of treatment plans was also noted.

Results: A total of 208 cases were presented to the tumor board representing 169 individuals who met study criteria. Types of disease included branch-duct Intraductal papillary mucinous neoplasm (BD-IPMN) (32.7%), serous cystadenoma (14.4%), main-duct IPMN (MD-IPMN) (13.9%), pseudocyst (5.8%), mucinous cystic neoplasm (MCN) (3.8%), and other/unknown cystic lesions (29.3%). Overall, post-tumor board diagnosis differed from preliminary 9.6% of the time, varying from other/unknown cystic lesion (23.0%), MCN (12.5%), BD-IPMN (5.9%), and serous cystadenoma (3.3%) (P=0.002). Tumor board recommendations differed from the proposed treatment plan for 44.2% of presented cases; where board recommendations differed from prior planning, tumor board recommended treatment was implemented for 66.3% of patients. Treatment change occurred most frequently with patients who presented with a preliminary diagnosis of serous cystadenoma (60%) followed by other cyst (55.7%), MD-IPMN (41.4%), MCN (37.5%), pseudocyst (33.3%) and BD-IPMN (30.9%) (P=0.034). Of those with a change in plan, 64.8% were from a less aggressive to more aggressive treatment option.

Conclusion: Presentation to a multidisciplinary tumor board is associated with a 9.6% change in diagnosis. A change in treatment recommendations was seen over 40% of the time, with a plan that is considered more aggressive being made in nearly 65% of these cases. Presenting patients with pancreatic cystic lesions to a tumor board may be useful when attempting to accurately diagnose and care for this patient population.

 

84.01 Surgical Resection in Stage IV Pancreatic Cancer: A Review of the SEER Database (2004-2013)

Posted on January 18, 2018

K. M. Turner1, C. J. Joyce1, A. R. Dhanarajan1, J. L. Gnerlich2  1Loyola University Chicago Stritch School Of Medicine,Maywood, IL, USA 2Louisiana State University Health Sciences Center,Surgery,New Orleans, LA, USA

Introduction: Over half of the patients diagnosed with pancreatic cancer have metastatic disease at presentation. Pancreatic resection is not considered an option for management of Stage IV pancreatic cancer; however, small institutional studies have shown a questionable survival benefit in select metastatic patients who underwent a pancreatectomy. For patients with low-volume metastatic disease and a good response to systemic therapy, questions regarding further management including surgery need to be addressed. Our aim is to determine if there is a survival advantage with surgical resection of the primary tumor in a large subset of patients with metastatic disease.

Methods:  We conducted a retrospective, population-based cohort study of Stage IV pancreatic adenocarcinoma patients using the 2004-2013 Surveillance, Epidemiology, and End Results (SEER) database to compare patients who underwent surgical resection with patients who did not. Associations between patient characteristics and surgery were assessed for statistical significance with chi-square tests. Median survival time was calculated using the Kaplan-Meier method. Univariable and multivariable Cox proportional hazards models were used to determine the hazard ratios for patient and treatment characteristics associated with mortality. 

Results: Of the 35,767 SEER patients with Stage IV pancreatic adenocarcinoma, 814 (2.3%) underwent pancreatic surgery and 34,953 (97.7%) did not receive surgery. Over the study time period, rates of pancreatic resection were similar. Overall, 6.0% of patients received radiation, 13.0% surgery group vs. 5.8% no surgery group (p<0.001). Patients who were younger, married, had lower grade, smaller tumors (<4cm), pancreatic head tumors, and those who received radiation were significantly more likely to undergo surgery (p<0.05 for each). On univariable Cox proportional hazards modeling, both radiation (HR: 0.68, 95% CI: 0.65-0.71) and surgery (HR: 0.47, 95% CI: 0.44-0.51) conferred a survival advantage. Median survival was longer for those who underwent surgery compared with those who did not undergo surgery (9 vs. 3 months, p<0.001). After adjustment for age, gender, race, tumor size, location, and radiation, surgery was associated with improved survival (aHR: 0.51, 95% CI: 0.47-0.56). Results were similar and remained significant in a sensitivity analysis considering cause-specific mortality.

Conclusion: Analysis of the 2004-2013 SEER data suggests that a subset of patients with Stage IV pancreatic cancer are undergoing surgery with improved survival. With increased survival times and response rates to multi-agent systemic therapy, future studies are needed to determine which metastatic patients will benefit from surgical resection.  

 

84.02 Tumor Biology Impacts Survival in Surgically Managed Primary Hepatic Vascular Malignancies

Posted on January 18, 2018

E. Dogeas1, A. E. Mokdad1, M. Porembka1, S. Wang1, A. Yopp1, P. Polanco1, J. Mansour1, R. Minter1, M. A. Choti1, M. M. Augustine1  1University Of Texas Southwestern Medical Center,Surgical Oncology,Dallas, TX, USA

Introduction: Hepatic angiosarcoma (AS) and hepatic epithelioid hemangioendothelioma (HEHE) are rare primary liver vascular malignancies that remain poorly understood. We sought to identify factors predicting survival after surgical intervention using a large national database in an effort to guide management.

Methods: In a retrospective analysis of the National Cancer Database (2004-2013) patients with a diagnosis of AS and HEHE were identified. Clinicopathologic factors were extracted. The Mann-Whitney U and chi-squared tests were used to compare the two disease groups. Overall survival (OS) was estimated with the Kaplan-Meier method and the Cox proportional hazards model was used to identify predictors of survival. 

Results: 137,051 primary liver malignancies were captured in the NCDB. AS was diagnosed in 390 (0.3%) and HEHE in 216 (0.1%) patients. AS patients were older (59 vs 46 years, p<0.001), male (64% vs 43%, p<0.001) and presented with larger tumors (7.9 vs 3.8 cm, p<0.001) that more commonly exhibited poor differentiation (25% vs 2%, p<0.001). Only 16% of AS and 36% of HEHE patients underwent surgery(p<0.001). The median OS in the entire cohort was 5 months, with AS patients exhibiting worse prognosis (5-year OS: 5% vs 51%, p<0.001).

Within the surgically-managed cohort (n=142), AS patients tended to be older (59 vs 46 years. p<0.001) and exhibited larger (6.5 vs 3.8 cm, p<0.001) and more poorly differentiated tumors (34% vs 5%, p<0.001). Surgical interventions, including ablation, minor and major hepatectomy, and liver transplantation were similar between the two histologic groups (p=0.128). Negative-margin resection was achieved in ~70% of both groups. The median OS for surgically-managed patients was 97 months, with 5-year OS of 30% for AS versus 69% for HEHE patients (p<0.001). Tumor biology strongly impacted OS, with AS histology conferring a Hazard Ratio (HR) of 3.61 (1.55-8.42), moderate/poor tumor differentiation a HR of 3.86 (1.03-14.46) and tumor size a HR of 1.01 (1.00-1.01). The presence of metastatic disease in the surgically managed cohort, HR: 5.22 (2.01-13.57), and involved surgical margins, HR: 3.87 (1.59-9.42), were independently associated with worse survival. Finally, patient age was negatively associated with OS, HR: 1.04 (1.01-1.07), while the type of operation was not (p=0.894).

Conclusion: In this national cohort, we identified factors that influence patient outcomes in surgically managed, primary hepatic vascular malignancies. AS histology, tumor differentiation and tumor size were strongly associated with survival. Residual tumor burden after surgical resection, in the form of positive surgical margins and the presence of metastasis, were negatively associated with survival. Despite attempts at curative-intent surgery for hepatic vascular malignancies, tumor biology impacts survival, emphasizing the need for effective forms of adjunctive systemic therapies for this group of malignancies.

83.10 Improving Patient Satisfaction with Same Day as Clinic Pediatric Surgery

Posted on January 18, 2018

C. N. Criss1, J. Brown1, J. Gish1, S. K. Gadepalli1, R. B. Hirschl1  1C.S.Mott Children’s Hospital,Pediatric Surgery,Ann Arbor, MI, USA

Introduction
Same Day Surgery (SDS) as clinic programs allow common surgical procedures to be performed the same day as the initial clinic evaluation. Implementation of an SDS program may improve efficiency but patient satisfaction is unclear.   We sought to assess the feasibility and overall patient satisfaction at our institution.

Methods
After IRB approval, pediatric patients presenting for SDS between 1/1/2014-12/31/2016 were carefully followed.   Patient families who did and did not choose SDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback.

Results
Twenty-seven patients received SDS, with inguinal hernia repair (30%) and umbilical hernia repair (26%) being the most common. Of the sixteen (59%) patients that agreed to the telephone survey, all parents (16/16) agreed the instructions were easy to understand, 81% (13/16) indicated that it decreased overall stress/anxiety, 75 % (12/16) stated that SDS allowed for less time away from work, and 94% (15/16) agreed to pursue SDS again if offered.  The most common negative feedback was an unspecified OR start-time (19%). There were no significant postoperative complications.

Conclusion
This study demonstrates the feasibility of performing both initial evaluation and surgical intervention on the same day for common pediatric procedures. Overall, patient families were satisfied with the program, reporting value from decreased anxiety and less time away from work. 
 

 

83.11 The Utility of PEEK Implants Adjacent to Sinus Cavities after Craniofacial Trauma

Posted on January 18, 2018

V. Suresh1, R. Anolik1, D. Powers1  1Duke University Medical Center,Durham, NC, USA

Introduction:  Poly(aryl-ether-ether-ketone) (PEEK) implants have become increasingly popular for use in trauma, orthopedic, and reconstructive procedures. PEEK’s utility is derived from chemical and mechanical properties such as temperature stability, water-resistance, and an elastic modulus that is close to that of human cortical bone. Additionally, both in vivo and in vitro studies have shown that PEEK exhibits good biocompatibility and generates minimal inflammatory responses after implantation. As the utilization of PEEK becomes more ubiquitous in the field of craniomaxillofacial trauma and reconstructive surgery, it is imperative to understand the potential consequence of employing this biomaterial in anatomic sites that may pose a risk of infection. Specifically, the use of PEEK in reconstruction of the walls of paranasal sinus cavities is not well documented in the literature. The primary aim of this study is to examine the rate of post-operative complications, namely surgical site infection and implant loss, in patients who have undergone craniomaxillofacial procedures with sinus cavity wall reconstruction using PEEK implants.

Methods: This study is a single center case series. All patients that underwent craniomaxillofacial reconstruction with a custom made PEEK implant in intimate contact with a functional paranasal sinus from June 1, 2013 to May 31, 2017 were included in this study. Baseline characteristics were collected via retrospective chart review. Mechanism of injury, operation time (measured from time of incision to closure), anatomic site of implant, size of implant, perioperative/post-operative antibiotic regimens, follow-up time, and post-operative complications (surgical site infection, readmission within 30 days of procedure, bleeding complications, loss of implant, and/or death) were recorded.

Results: A total of 8 patients were included in this case series. The average age of these patients were 45.75 ± 19.36 years old. Mechanisms of injury ranged from self-inflicted gunshot wounds to facial trauma following an explosion. Average follow-up duration was 300 ± 263 days. The mean operative time for PEEK implantation was 214.13 ± 66.03 minutes and implants ranged in size from approximately 5 sq cm to nearly 100 sq cm. One patient underwent explantation of his PEEK implant secondary to breakdown of the overlying skin due to coagulase-negative S. epidermis infection. No patients were diagnosed with acute or chronic sinusitis after implantation of their custom-designed PEEK implants.

Conclusions: A review of the literature indicates that this is the largest case series reported to date documenting the use of PEEK implants in reconstruction of the walls of the paranasal sinuses.  The authors conclude that PEEK implants may be safely utilized in craniomaxillofacial procedures that involve paranasal sinus cavities without increasing the risk of infection and need for explant.

83.12 Efficacy of a Surgical Site Infection Scorecard for Quality Improvement in Haiti

Posted on January 18, 2018

J. A. Codner1, A. Farrell1, C. Brownfield1, C. Haack1, J. Srinivasan1, J. Sharma1  1Emory University School Of Medicine,Atlanta, GA, USA

Introduction:  Surgical site infections (SSI) are one of the main complications to arise after any type of surgery. These complications are compounded in low resource settings, where patients have less follow up care, and hospitals have less means to deal with the sequelae of surgical wound infections. SSI can contribute to more severe complications including sepsis and mortality. For these reasons, it becomes even more important to prevent the development of a SSI in low and middle income countries (LMIC). The WHO produced a “Safe Surgery Checklist” for the prevention of SSI for global surgery. Our goal with this project was to track the risk factors specified by the WHO in our patients over a 4-week surgical mission trip to Pignon, Haiti by using an SSI scorecard system. The scorecard was used to stratify each patient’s risk of SSI, and overall variable incidence data was then used to evaluate quality improvement steps for the prevention of SSI on subsequent trips to Haiti.

Methods:  An eleven-element SSI scorecard was completed for each operative patient (n= 54), General Surgery (n=32), Urology (n=10), and Head & Neck (n=12). The cumulative value of the scorecard was used to risk stratify each patient for development of SSI. (0-2)-Low Risk (n=18), (3-4)- Intermediate Risk (n=30), (>4)- High Risk (n=6). We then calculated the incidence of each variable for the entire study population.

Results: Follow-up was performed in 41 patients with a mean follow up of 8.6 ± 4.9 days. We had 2 patients with an SSI in our cohort (4.8% n=41). These patients with SSIs had scores of 3 and 5, a perineal incision and a prostatectomy, respectively. Mean score of the scorecard was 2.9 ± 1.2 (n=54). Variable Incidence (n=54): Age >50 (30%), Malnutrition (BMI <18.5) (17%), Pre-op Antibiotics (Abx) not indicated (22%), Surgery time > 1 hr (54%), Clean Contaminated (39%), Contaminated (4%), Drain Indicated and not placed (9%) (n=11), No Post-op Abx (54%).

Conclusion: Implementation of scorecards can help stratify SSI risk and guide antibiotic stewardship preoperatively and postoperatively in LMIC. SSI risk is highly variable and should be assessed for individual patients undergoing surgery.

83.09 Implementation of a Standardized Data-Collection System for Comprehensive Appraisal of Cleft Care

Posted on January 18, 2018

P. Bittar2, A. Carlson1, A. Mabie3, J. Marcus1, A. C. Allori1  1Duke University Medical Center,Plastic Surgery,Durham, NC, USA 2Duke University School Of Medicine,Durham, NC, USA 3Duke University Medical Center,Otolaryngology & Communication Sciences,Durham, NC, USA

Introduction:  Long-term outcomes research for cleft lip and/or palate has been challenging. In 2016, a “standard set” of outcome measures for appraisal of cleft care was proposed by the International Consortium for Health Outcomes Measurement (ICHOM); however, this conceptual framework must be translated into a practical framework customized for specific constraints that exist in each center. Our objective is to describe the process of adapting a conceptual framework into a practical toolkit for one cleft team.

Methods:  This is a single-arm implementation study in a single institution. Implementation took place in a mid-sized multidisciplinary team operating a weekly clinic for patients with cleft lip and/or palate from urban/suburban and rural areas across North Carolina and neighboring states. Eligible subjects were patients from English-speaking families with cleft lip and/or palate receiving treatment at our center. Our intervention was the implementation of a prospective data-collection system based on the ICHOM standard set of outcome measures for cleft lip and/or palate. Implementation was accomplished in multiple stages. Patient- and clinician-reported forms and protocols for gathering data were created. Team members were then trained and the system was tested; finally, the system was deployed. 

Results: Success of the implementation was appraised using the RE-AIM framework to assess reach, effectiveness, adoption, implementation, and maintenance. 98% of eligible patients and all cleft team members agreed to participate. 94% of required standard set data points were captured. Adaptations to friction points were made; specifically, visible reminders were affixed to charts, primary clinicians were required to assume data-entry responsibility, and email reminders were instituted. Development cost for the system was $7707, and average time cost per clinician was 21 minutes/week.

Conclusion: All conceptual frameworks for outcomes studies must first be tailored to suit the environment; otherwise, they cannot be practically implemented and sustained. In this paper, we present this process for a cleft team using the ICHOM standard set. The process may help other teams in implementing the standard set or other conceptual frameworks within their own hospitals.

 

82.19 Lipomatous Mass with Highrisk Radiographic Features:Is Routine Corebiopsy Warranted before Excision?

Posted on January 18, 2018

V. Satyananda1, C. Dauphine1, D. Hari1, K. Chen1, J. Ozao-Choy1  1Harbor UCLA Medical Center,General Surgery,Los Angeles, CALIFORNIA, USA

Introduction:  

Lipomatous masses are the most frequent non-cutaneous soft tissue masses encountered in clinical practice. Benign Lipomas comprise the majority,however,it is necessary to differentiate these from malignant lesions for which adequate surgical margins are important. In the abscence of suspicious clinical features, such as overlying skin changes,rapid growth,pain and firmness on examination, radiographic features have traditionally been to determine which patients should undergo core needle biopsy (CNB) prior to excision. We sought to examine whether CNB should be routinely performed in all lipomatous masses that demonstrate high -risk radiographic features

Methods:
A retrospective chart review of all patients who underwent excision of extremity or truncal lipomatous masses at a single institution between October 2014 to July 2017. Patients were divided into three groups-those who did not undergo pre-operative imaging or CNB(Group 1), those who underwent imaging (ultraosund, CT or MRI)without  CNB (Group 2) and those who underwent both imaging and CNB(Group 3). High risk radiographic features were defined as size > 5 cm , intramuscular location, presence of septationa (either < 2mm or > 2mm) and presence of areas of non -fat nodularity within the lesion. the number of high risk features present, pathologic results of surgical excision were evaluated to determine the subset of patients most likely to benefit from CNB.

Results:
In the 58 month study period, 182 patients underwent excision of lipomatous mass. Of these, 57 patients (Group1) had no preoperative imaging or CNB, and all were found to have benign lipotamous masses. In the remianing 125, 70 had imaging only(Group 2) and 55 had both imaging and CNB performed (Group 3). Overall, 2 patients (1.1%) were found to have atypical or malignant lipomatous lesions. Both had > 3 high risk features (thick/thin septations, intramuscular location, size >5cm)and both had undergone CNB( Table 1).

Conclusions:
Few recommendations exist regarding management of lipomatous masses; current guideline suggest imaging and CNB should be performed on large (> 5cm ) and /or high risk radiological features. Nonetheless, the rate of malignancy in these lesions appears to be low. Only 1% of our patients had an atypical or malignant final pathology. Our data suggests that patients who have small lipomatous masses (< 5 cm) may undergo excisional biopsy without further imaging or CNB. in additiona, our study suggests that routine performance of CNB based upon size alone is not warranted , but presence of 3 or more high-risk radiographic features should indicate pre operative CNB to ensure proper surgical approach at the time of excision. 

82.15 Surgical Performance Dashboard Analysis Affirms that Hypertension is a Biomarker of Surgical Risk

Posted on January 18, 2018

L. A. Gurien1, J. Ra1, H. Kendall1, L. Palmer1, A. J. Kerwin1, J. J. Tepas1  1University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA

Introduction:
The NSQIP dataset tracks specific patient comorbid conditions (CM) and post-operative adverse events (AE). While CM do not always cause AE, analysis of a matrix of concurrent CM and AE demonstrates interaction of CM and AE to define risk from a population perspective. Using our surgical performance dashboard which tracks population risk, categorizes effect of AE using the Clavien-Dindo (C-D) system, and ranks individual provider performance, we evaluated the effect of our surgical quality program over a four year period. We hypothesized that the dashboard would document dominant risk factors, guide analysis of “unexpected” AE occurring with no CM, track AE effect, and define specific procedures and providers for focused assistance in managing risk.

Methods:

Two 12-month cohorts of general-vascular cases from 2013-14 and 2016-17 were evaluated. We analyzed concomitant occurrence of CM and AE to define most common CM with highest AE rate, and most common AE and associated CM. “Unexpected” AE without CM were analyzed by CPT and type of AE. The impact of AE regarding additional resource consumption was compared across study periods using Wilcoxon matched pairs test accepting p<.05 as significant. Reflecting a “march to zero”, individual performance was measured as a surgeon’s proportion of AE divided by proportion of cases performed. Scores within the group mean ±1 SD were classified as “expected” and lower outliers as “exceptional”.

Results:

The 2013-14 cohort consisted of 651 cases with 21% (n=137) incidence of AE. The 2016-17 cohort consisted of 596 cases with 20% (n=120) incidence of AE. For both groups, hypertension was associated with highest incidence and severity of AE, and transfusion within 72 hr. was the most common AE. C-D effect analysis demonstrated a shift over time to less severe AE (Figure), although not statistically significant (p=.625). Of cases with unexpected AE based on no CM, 90% were elective oncologic procedures with infection and sepsis as the most common AE. Provider performance over time identified the same surgeons with the highest AE/volume; however scores improved over time for >50% of participants.

Conclusion:

This dashboard analysis demonstrates that hypertension, which is often clinically silent, is a population time bomb for adverse surgical outcome.  Review of cases with unexpected AE illustrated the primacy of optimization and infection control as major adjuncts in these mostly elective complex cases. Individual provider and group performance identified quality improvement over time and a consistent provider cohort whose case mix mandates more aggressive preemptive strategies for avoidance of adverse events.

82.16 Revised Cardiac Risk Index Poorly Predicts Cardiovascular Complications after Adhesiolysis for SBO

Posted on January 18, 2018

D. Asuzu1, G. Chao1, K. Y. Pei1  1Yale University School Of Medicine,Department Of General Surgery,New Haven, CT, USA

Introduction:

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) universal surgical risk calculator estimates risk of postoperative cardiovascular complications with a good to excellent overall accuracy in the NSQIP dataset (c-statistic 0.895). However, the NSQIP calculator requires up to 21 variables for prediction including intraoperative details, and its retrospective use is limited by unavailability of individual regression coefficients. The Revised Cardiac Risk Index (RCRI) can be readily estimated prospectively or retrospectively using only six clinical variables, however its accuracy in large surgical datasets has not been tested. Our objective was to determine accuracy of the RCRI for predicting cardiovascular complications after adhesiolysis for small bowel obstruction (SBO) using the NSQIP dataset. 

Methods:
8,196 cases of open or laparoscopic adhesiolysis (Current Procedural Terminology codes 44005 and 44180) for SBO (International Classification of Diseases, tenth edition 560.81 and 560.9) were analyzed from 2005 to 2013 using the NSQIP dataset. RCRI estimates were calculated for each case and compared to reported cardiovascular complications (myocardial infarction or cardiac arrest) using univariable logistic regression. Overall predictive accuracy was assessed by measuring model discrimination (c-statistics) and model calibration (Hosmer-Lemeshow Chi-squared statistics).  

Results:

RCRI predicted cardiovascular complications with odds ratio 1.96, 95% confidence interval (CI) 1.54 – 2.50, P < 0.001. However, c-statistic was poor (0.64, 95% CI 0.59 – 0.68), and Hosmer-Lemeshow Chi-square did not reach statistical significance (X2 35.49, P < 0.001, 3 groups) indicating low model discrimination and calibration.

 

Conclusion:

Despite its relative computational simplicity, the RCRI performed poorly as a predictor of cardiovascular complications after adhesiolysis for SBO. These findings call into question the utility of the RCRI in this patient population. Future studies should aim to develop models that are computationally simple while retaining predictive accuracy. 

82.13 Is Intraoperative Assessment of Small Bowel Resection Accurate?

Posted on January 18, 2018

W. I. McKinley1, B. Strollo1, M. Benns1, A. Motameni1, N. Nash1, M. Bozeman1, K. Miller1  1University Of Louisville,Department Of Surgery,Louisville, KENTUCKY, USA

Introduction: Enterectomy is a commonly performed procedure in trauma and acute care surgery but the term is nebulous in regard to the extent of bowel resected.  There is wide variation in practice between intraoperative assessment of bowel length and the accuracy of that assessment is unknown.  The aim of this study is to determine the accuracy and frequency of intraoperative assessment of bowel length.

Methods: After obtaining IRB approval retrospective chart review was performed of patients from three centers in Louisville, KY having undergone enterectomy (CPT codes 44120, 44202) from 2012-2016.  Patients were excluded if lacking pathology or an operative report.  Subgroups (0 to <10cm, 10 to <30cm, 30 to <50cm, and >50cm) were created based on length dictated by the operative surgeon.  Groups were compared using a 2-tailed Student’s t-test.

Results: 174 patients were included in the study (219 bowel resections) of whom 106 did have an estimate of bowel length resected (48.4%). 24 patients had <10cm removed, 47 patients had 10-30cm removed, 18 patients had 30-50cm removed, and 17 patients had >50cm removed.  Estimated bowel length <10cm showed a statistically significant underestimation in comparison to pathologic specimen, and larger resections tended to be overestimated.

Conclusion: Documentation regarding extent of bowel resected at our institution was poor, as surgeons dictated estimated length in less than half of cases.  Surgeons underestimate short segment resections while overestimating on extensive (>50cm) enterectomy.  Documentation of extent of enterectomy should be standardized and can have future clinical implications.

 

82.14 Outcomes of Femoral Hernias in Veteran Patients

Posted on January 18, 2018

L. R. Taveras Morales1, S. Huerta1,2  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2VA North Texas Health Care System,Department Of Surgery,Dallas, TX, USA

Introduction: Femoral hernias are much less common than inguinal hernias (2-4% of all groin hernias).  An analysis of 3,980 femoral hernias showed that femoral hernias were more common in women compared to men (63% vs. 37%) and are more likely to present with a hernia complication compared to inguinal hernias (36% vs. 4.9%).  The aim of the present study is to determine incidence and outcomes in patients with groin hernias at a veteran affairs hospital. 

Methods: A retrospective analysis of a prospectively maintained database of a single surgeon’s practice over 12 years (2005-2017) at the VA North Texas Health Care System (VANTHCS). The database included 1153 consecutive groin hernias in 1062 patients. Wilcoxon rank-sum test and Fisher’s exact test were used to compare the continuous and categorical outcomes, respectively. Patient postoperative morbidity was explored in a multivariable logistic regression model. The model was constructed using a forward stepwise technique.

Results:  Of 1153 inguinal hernias performed by the same surgeon over a 12-year period, 15 were femoral (1.3%).  The hernia sac contained an inflamed appendix in one of them (0.09%).  Patients with femoral hernias were older (64.7 ± 17.7 vs. 63.0 ± 5.9; p = 0.03), more likely to present with an incarcerated groin hernia, and would require a small bowel resection more frequently.  Complications following a femoral hernia were higher compared to inguinal hernias (Table). 

Conclusion: Femoral hernias are uncommon in veteran patients. A veteran patient presenting with an incarcerated groin hernia is likely to have a femoral hernia. 

82.12 Laparoscopic versus Open Bowel Resection for Small Intestine Diverticulitis

Posted on January 18, 2018

M. P. DeWane1, A. S. Chiu1, I. Rezek1, K. Y. Pei1  1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction: Small intestine diverticulitis is rare and individual surgeon operative experience is generally limited.  As such, optimal surgical management is unknown. This study addresses this knowledge gap by comparing outcomes of laparoscopic versus open operative management of small intestine diverticulitis.

Methods:

This analysis was a retrospective review of the prospectively gathered American College of Surgeons National Surgical Quality Improvement Project from a 5 year period (2010-2014). Patients included for analysis had a primary diagnosis of small intestine diverticulitis (ICD-9 code 562.01) and a primary or secondary procedure listing that indicated bowel resection. Patients were stratified as having undergone either laparoscopic versus open management.

Multivariable logistic regression models controlling for patient variables and comorbidities were constructed to examine risk factors for undergoing extended hospital length of stay (5 days), prolonged operation time (3 hours) or presence of any postoperative complication (including neurologic, cardiac, respiratory, bleeding, renal, infectious, thromboembolic, or wound complications). These models were constructed in a backwards fashion and utilized an inclusion value of 0.1 and significance value p<0.05.

Results: A total of 295 patients were included in this analysis, 22.4% of whom underwent laparoscopic operations. Selected variables and outcomes stratified by cohort are shown in Table I. Emergency cases were more likely to be completed in an open fashion but there were no significant differences in mortality between the operation types. Reoperations were more prevalent in the open cohort. Patients undergoing laparoscopic versus open operation had lower odds of having an extended length of stay (Odds Ratio [OR]: 0.28, p<0.001) and developing any complication (OR: 0.31, p=0.039) and increased odds of undergoing a prolonged operation (OR: 3.67, p<0.001). 

Conclusion: Surgical experience for small bowel diverticulitis is rare. Laparoscopic resection performed for small bowel diverticulitis is associated with decreased length of stay and complications. The laparoscopic approach should be considered a safe option in appropriate patients who can tolerate prolonged operations.
 

82.11 Outcomes of GI Operations in Neutropenic Patients

Posted on January 18, 2018

M. Harary1,2, J. S. Jolissaint2, A. Tavakkoli1,2  1Harvard Medical School,Boston, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction:  Surgery in neutropenic patients is often avoided due to presumed increased morbidity and mortality although limited data on actual outcomes is available. Here, we report on post-operative outcomes in neutropenic patients undergoing abdominal surgery, stratifying the severity of neutropenia to examine whether there is a critical number below which surgical risks are significantly different.

Methods:  We performed an institutional database search between 1988-2017 to identify patients who were neutropenic in the 24-hours prior to undergoing abdominal surgery. Endoscopic and percutaneous procedures were excluded. Neutropenia was defined as an Absolute Neutrophil Count (ANC) of <1500, determined either via direct measurement or extrapolation from leukocyte values. Patient outcomes were extracted by chart review. Severity of neutropenia was stratified as mild (1,000<ANC≤1,500), moderate (500<ANC≤1,000) or severe (ANC≤500). Comparisons were made using two-sided ANOVA, Kruskall-Wallis test, Chi-Squared test and binary logistic regression on SPSS.  

Results: A total of 134 patients were identified with a mean age of 56 years (SD 15.8); 41% were male. Of these, 69, 37, and 29, were mildly, moderately, and severely neutropenic, respectively (see Table). These subgroups did not vary significantly in age or gender distribution (F(2,131,) p=0.821, p=0.388).  Rates of 30-day mortality significantly vary among the subgroups (p=0.02) with 2.9%, 16.2% and 27.6%, in the mild, moderate and severe neutropenic respectively. The presence of severe neutropenia and urgency of procedure were both independent predictors of 30-day mortality (p=0.013, p=0.02). Severity of neutropenia was not a predictor of 30-day morbidity, ICU stay, disposition status, length of stay or likelihood of 30-day readmission. Overall, 61.2% of procedures were performed as an emergency.  These cases were associated with significantly higher rates of 30 days morbidity in the moderate and severe neutropenia subpopulations (p=0.028, p=0.026) and higher rates of ICU stay in the moderate group (p=0.032), compared to non-urgent cases in the same neutropenia group

Conclusion: Abdominal surgery in neutropenic patients, particularly in those with ANC<1,000, is associated with high rates of mortality regardless of etiology of the neutropenia. Ideally, surgery should be delayed whenever possible in order to allow ANC to rise, however this needs to be balanced against the possibility of an acute worsening and need for emergency surgery which is associated with a significant further increase in mortality.
 

82.07 Significant Proportion of Small Bowel Obstructions Require > 48 Hours to Resolve after Gastrografin

Posted on January 18, 2018

M. B. Mulder1, M. D. Ray-Zack2, M. Hernandez2, D. Cullinane4, D. Turay5, S. Wydo3, M. Zielinski2, D. Yeh1  5Loma Linda University School Of Medicine,Department Of Surgery,Loma Linda, CA, USA 1University Of Miami,Ryder Trauma Center: Division Of Trauma And Surgical Critical Care,Miami, FL, USA 2Mayo Clinic,Division Of Trauma, Critical Care, And General Surgery,Rochester, MN, USA 3Cooper University Hospital,Department Of Trauma Surgery,Camden, NJ, USA 4University Of Wisconsin,Department Of Surgery Marshfield Clinic,Madison, WI, USA

Introduction:  Gastrografin (GG)-based non-operative approach is both diagnostic and therapeutic for partial small bowel obstruction (SBO).  Absence of x-ray evidence of GG in the colon after 8 hours (h) is predictive of the need for operation and a recent trial used 48 h to prompt operation.  We hypothesize that a significant number of patients receiving the GG challenge require >48 h before an effect is seen.

 

Methods: In this post-hoc analysis of a multi-institutional SBO database, only patients receiving the GG Challenge were included. We excluded those without a nasogastric tube (NGT), NGT removal on the same day as insertion, and flatus before NGT insertion. Date of NGT insertion and removal were used to calculate the number of days of NGT decompression.  Passage of flatus and NGT removal were used as surrogate endpoints for evidence of passing the GG Challenge. “Hard” preoperative signs for operation included: closed loop obstruction, septic shock, and peritonitis. Multiple logistic regression analysis controlling for age, prior abdominal operation, and prior SBO exploration was performed to identify predictors of delayed (>48 h) GG Challenge effect.

 

Results: Of 319 patients receiving GG, 225 patients (71%) were successfully managed non-operatively (mean age 64  ±  16 years; 56% female).  X-ray was performed after a median 8 [4-8.5] h and GG was observed in the colon in 179 (80%). A total of 64 patients (28%) had NGT decompression for >48 h (n=58) or required >48 h to pass flatus (n=37), with some requiring both (n=21).  By 4 days, 215 (96%) of those who successfully passed the GG challenge had passed flatus.  Regression analysis demonstrated that previous abdominal surgery was predictive (OR 0.37 [0.16-0.88], p=0.024) of a delayed GG Challenge effect.  Ninety-four patients (29%) receiving GG underwent operative exploration (mean age 63 ±  17 years; 61% female).  X-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 17 (18%).  Of the 94 undergoing operation, 24 (25%) underwent operation before day 4 without “hard” signs and also did not have intraoperative findings of strangulation, perforation, or require bowel resection.  In these 24 subjects, x-ray was performed after a median 8 [6-9] h and GG was observed in the colon in 6 (25%). 

 

Conclusion: A significant proportion of patients (20%) “failed” the 8 h GG Challenge but were successfully managed non-operatively.  At 48 h, a large proportion (28%) still required NGT or had not yet passed flatus, but were nevertheless successfully managed non-operatively.  Extending the GG Challenge to 96 h may help avoid operation in some patients, especially those without previous abdominal surgery.

82.08 Microbiological Patterns and Sensitivity in Necrotizing Soft Tissue Infections in Rwanda

Posted on January 18, 2018

M. CHRISTOPHE1, J. Rickard2,3, F. Charles1,4, N. Faustin1,3  1University Of Rwanda,College Of Medicine And Health Sciences,Kigali, KIGALI, Rwanda 2University Of Minnesota,Surgery And Critical Care,Minneapolis, MN, USA 3University Teaching Hospital Of Kigali,Surgery,Kigali, KIGALI, Rwanda 4Rwanda Military Hospital,Plastic And Reconstructive Surgery,Kigali, KIGALI, Rwanda

Introduction: Necrotizing soft tissue infections (NSTI) remains a challenging emergency surgical condition with rapid clinical deterioration, microbiological variability and increased morbidity and mortality

Methods: This prospective cohort study includes all patients managed in Department of Surgery, University Teaching Hospital of Kigali (CHUK) from April 2016 to January 2017 with NSTI. The objective was to describe patients’ demographics, involved tissue planes, bacterial pathogens involved, antimicrobial sensitivity patterns and outcome of care. Analyses were conducted using student t-test for continuous variables and Pearson chi-square test for categorical variables. P-value < 0.05 was considered significant

Results:A cohort of 175 patients with confirmed diagnosis of NSTI was recruited during the study period. Monomicrobial organisms were identified in 57% of cases: Klebsiella spp (n=28, 16%), Escherichia coli (n=22, 13%, Proteus spp (n=20, 11%, and Staphylococcus aureus (n= 19, 11%. Fifty one (29 %) patients had no bacterial growth. The overall isolated germs were gram negative (n=121, 81%) with predominance of klebsiella spp (n=38, 25%).  Third generation cephalosporins were prescribed in 136 (78%) patients. Forty to sixty five (40-65%) of commonly isolated organisms (klebsiella spp, Escherichia coli) were resistant to most used antibiotics (third generation cephalosporins). The overall mortality was 26%.  The median length of hospital stay was 23days (IQR: 8-41). 

Conclusion:NSTIs are found to be predominantly mono-microbial with high resistance to 3rd generation cepahalosporins. A large scale antibiogram study is needed to guide clinician decision making for empirical antibiotic coverage in NSTI in order to improve patients’ outcomes.

 

82.05 Timing of Post-Operative Complications after Major Abdominal Surgery Varies by Age

Posted on January 18, 2018

C. Bierema1, A. J. Sinnamon1, C. E. Sharoky1, C. J. Wirtalla1, R. E. Roses1, D. L. Fraker1, R. R. Kelz1, G. C. Karakousis1  1University Of Pennsylvania,Philadelphia, PA, USA

Introduction:  The relationship between patient age and timing of postoperative complication is unknown. We hypothesized that advanced patient age may be associated with later presentation of certain common complications following major abdominal surgery.

Methods:  

The American College of Surgeons National Surgical Quality Improvement Program (2001-2011) was used to evaluate timing of postoperative complications in patients undergoing elective major abdominal surgery (colectomy, gastrectomy, hepatectomy, and pancreatectomy). The Jonckheere-Terpstra test was used to assess for significant trends in age and later median postoperative day of complications. Multivariable linear regression adjusting for patient factors was then performed to examine the association between older age and timing of postoperative complications.

Results: 

A total of 108,689 patients met inclusion criteria. There were 8,834 patients <40y (8%), 54,040 patients 40-65y (50%), 36,834 patients 66-80y (34%), and 8,891 patients >80 y (8%). More than half the patients (58%, n=63,004) underwent colectomy. The remainder of the cohort underwent pancreatectomy (26% n=28,388), hepatectomy (10% n=10,687), and gastrectomy (6% n=6,610).  Significant differences in comorbid status by age group were observed. Before adjustment for patient factors, the median number of days to complication for urinary tract infection (p<0.001), pneumonia (p<0.001), superficial surgical site infection (p<0.001) and deep/organ space surgical site infection (p=0.046) was significantly longer with increasing age (see figure). There was no significant difference between median days to complication and age for venous thromboembolism, cardiac or renal complications. After adjustment for patient factors, a significant association between older age and later median day of complication presentation was only observed for urinary tract infection (p<0.001) and pneumonia (p<0.001). Other patient factors being equal, patients >80 years of age presented on average 2.56 days later with urinary tract infection and 1.46 days later with pneumonia than patients <40 years of age.

 

Conclusion: Urinary tract infection and pneumonia present later postoperatively with increasing age. Further study is needed to delineate whether these represent biological differences or delay in diagnosis, as elderly patients may not present with the same classic symptoms as younger patients. Recognition of these trends is important in the postoperative care of elderly patients, which is particularly relevant with the aging population. 

82.06 Staphylococcus aureus Nares Colonization Rates and Decolonization Efficacy of Povidone-Iodine

Posted on January 18, 2018

D. S. Urias1, J. Di Como1, K. Curfman1, M. Marley1, W. Carney1, D. Duke1, R. Dumire1, S. Morrissey1  1Conemaugh Memorial Medical Center,Johnstown, PA, USA

Introduction:
Surgical site infections (SSIs) are the most common hospital acquired infections (HAIs), although rare in abdominal wall hernia repair it is one of the most dreaded complications. Bundle protocols using chlorhexidine-gluconate (CHG) bath, nasal S. aureus decolonization with povidone iodine, and standard preoperative antibiotics have been proven in multiple trials to decrease SSIs. Because of these findings, we added a nasal decolonization bundle protocol to most surgical procedures with similar results. To better understand the impact of this key portion to the bundle protocol, we investigated colonization prevalence to provide insight as to the actual (practical) decolonization efficacy.

Methods:
A prospective observational study enrolling patients undergoing elective abdominal wall hernia repair with mesh. All patients were instructed to bathe with CHG the night before and morning of surgery, preoperatively a nasal culture for S. aureus was obtained from the nares, the nares were then swabbed with povidone-iodine nasal swabs, standard preoperative antibiotics were administered and the patient underwent the procedure. Postoperative nasal cultures for S. aureus were also obtained. Pre and post colonization prevalence were compared, thereby providing an estimate of the actual efficacy of our decolonization protocol in eliminating S. aureus in the nares.

Results:
To date, 80 patients have been consented and enrolled, with 54 patients completing all steps of the bundle and culture series. The study sample demographics include 91% males, mean age 59, mean BMI 29 and mean ASA was 2. The mean length of surgery was 47 minutes and the mean time from end of surgery to obtaining the post decolonization s. aureus nasal culture was 105 minutes.  For our study sample, the estimated prevalence of colonization with MRSA and/or MSSA is 22.2% (12/54) pre decontamination (11 MSSA, 1 MRSA, 0 positive for both) and 9.25% (5/54) after decontamination and surgery (5 MSSA and 0 MRSA), yielding an approximate 68% decontamination efficacy.

Conclusion:
Decreasing the rate of SSIs is a task assumed by a variety of departments within the health system using numerous methods. Evidence based decontamination protocols such as the one we have implemented are being successfully used to decrease SSIs. We have used our protocol in orthopedic and neurosurgical procedures and now have successfully expanded the protocol to repairs of abdominal wall hernias with mesh. The efficacy of povidone iodine in our study population although not as high as stated in recent literature, it does provide evidence for its use in a bundle protocol to decrease SSIs.
 

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